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Any Lab Test Now with Marker Insurance

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Business Owners Questionnaire - ALTN

Business Name

dba Any Lab Test Now

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Name Insured:

First Name Last Name

Location Address

Street Address Address Line 2 City State/Prov./Region ZIP/Postal

Phone Number

Cell Number

Contact Person

Name

First Name Last Name

Landlord Name and Address:

Fax:

Is this also an ArcPoint Franchise?

Yes

ArcPoint Company Name

Tax ID #

Description of Business

Years in Business:

Number of Employees:

Tax ID Number:

Medical Director:

Loss Information:

Gross Sales:

Payroll:

Property Information

Building

Number of Stories:

Square Feet:

Construction type:

Year Built:

Building Updates

Roof:

Plumbing:

Electric:

Heating:

Alarm:

Other occupants in building:

Building/Additions & Alterations Limit: (cost of buildout)

Deductible:

Content Limit:

Deductible:

If new, Effective Date of opening:

Additional Information:

Please do not include sensitive, private information in this area.

Additional Attachments: (landlord requirements)

Drop files here or

Max. file size: 300 MB.

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